1295050516 NPI number — DR. LAWRENCE CLIFFORD WALLEN III D.C.

Table of content: DR. LAWRENCE CLIFFORD WALLEN III D.C. (NPI 1295050516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295050516 NPI number — DR. LAWRENCE CLIFFORD WALLEN III D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLEN
Provider First Name:
LAWRENCE
Provider Middle Name:
CLIFFORD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295050516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21740 S TAMIAMI TRL
Provider Second Line Business Mailing Address:
#103
Provider Business Mailing Address City Name:
ESTERO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33928-2819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-676-9116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21740 S TAMIAMI TRL
Provider Second Line Business Practice Location Address:
#103
Provider Business Practice Location Address City Name:
ESTERO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33928-2819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-676-9116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301009662 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH10733 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008271600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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